Subcutaneous emphysema in cavitary pulmonary tuberculosis without pneumothorax or pneumomediastinum

Risk factors for extensive subcutaneous emphysema after pulmonary resection by video-assisted thoracoscopic surgery: a case-control study

Introduction

Extensive subcutaneous emphysema may lead to a significantly prolonged hospital stay, cosmetic problems, and even death without timely treatment. However, the risk factors for it have been poorly studied.

Aim

To clarify the prevalence and risk factors of extensive subcutaneous emphysema after pulmonary resection by video-assisted thoracoscopic surgery.

Material and methods

This is a retrospective matched case-control study. A sample of 86 cases and 258 matched controls was recruited from among 4339 patients admitted to the thoracic surgery department from October 2018 to October 2020 in a tertiary teaching hospital in China. Cases were patients who were diagnosed with extensive subcutaneous emphysema after pulmonary resection through video-assisted thoracoscopic surgery. Controls were matched in a ratio of 3 : 1 to the cases based on age and sex.

Results

In this study, the incidence rate of extensive subcutaneous emphysema was 2.05%, and approximately 75.58% of the cases occurred within 1 to 4 days postoperatively. In univariate analysis, patients with extensive subcutaneous emphysema were also likely to have a significant lower body mass index, worse pulmonary function, greater intraoperative blood loss, longer time of operation, history of lung surgery, wider scope of surgery, and more extensive pleural adhesion. The results of multivariate logistic regression showed that segmentectomy (OR = 3.130, 95% CI: 1.055-9.283, p = 0.040), lobectomy (OR = 4.487, 95% CI: 1.704-11.812, p = 0.002), and extensive pleural adhesion (OR = 4.514, 95% CI: 1.763-11.556, p = 0.002) were independent risk factors.

Conclusions

Segmentectomy, lobectomy, and extensive pleural adhesions were identified as independent risk factors for extensive subcutaneous emphysema after video-assisted thoracoscopic surgery.

A study of subcutaneous emphysema, factors contributing to its development, resolution and management with different modalities

Subcutaneous emphysema (SE) is defined as an escape of air in subcutaneous tissue. It is one of the most common complications after intercostal chest tube drainage. SE is usually benign, requiring no specific treatment, but extensive SE can be uncomfortable and alarming for the patient. It can rarely lead to airway compromise, respiratory failure, and death. Factors leading to its development, following chest tube insertion and methods of management, have not been extensively studied and published. This was an analytical study done over 2 years on indoor patients who developed SE. These cases were managed using four different modalities and were analyzed for various factors contributing to the development, severity, and resolution of SE. The results of this study highlight that the cases of hydropneumothorax and secondary pneumothorax were significantly more predisposed to the development of severe SE (following intercostal chest tube insertion) and large air leaks as compared to others. A larger air leak develops higher grades of SE. The average time for resolution of SE was similar among the different modalities of management compared in the study.

An unusual cause of pneumomediastinum and acute respiratory distress syndrome

Background

Progressive acute respiratory failure with Mycobacterium tuberculosis (TB) in immunocompetent individuals is rare, and if detected early, diagnosis and treatment dilemmas can be limited. We report here a unique case of respiratory failure due to tubercular spontaneous pneumomediastinum complicated by acute respiratory distress syndrome (ARDS).

Case presentation

A 24-year-old male of low socioeconomic background presented with shortness of breath, dry cough, and fever for 7 days, which was accompanied by weight loss and a reduced appetite. The patient had tachypnea and hypoxemia (SpO2 = 86%). The patient’s condition deteriorated (SpO2 = 72% with 12 L min−1of O2 delivered using a non-rebreather mask), and he was intubated using a lung-protective approach with a tidal volume of 350 mL (6 mL kg−1), positive end-expiratory pressure (PEEP) of 5 cm H2O, RR of 20 cycles/min, a flow rate of 35 L min−1, and FiO2 of 0.6. High-resolution computer tomography of the thorax showed multilobar consolidation, pneumomediastinum, and extensive subcutaneous emphysema with left-sided pneumothorax. Subsequently, a left-sided tube thoracostomy was carried out. The PaO2/FiO2 (P/F) ratio immediately after intubation was 130 and rose to 170 post-thoracostomy, which was suggestive of moderate ARDS. Bacterial and fungal colonies detected from the blood and endotracheal aspirate were normal. However, for the endotracheal aspirate, the cartridge-based nucleic acid amplification test (CBNAAT) detected TB with no rifampicin resistance. The patient was started on anti-tubercular therapy (ATT). Despite ATT, the patient developed circulatory shock and died after 4 days.

Conclusions

In young patients with acute spontaneous pneumomediastinum and ARDS, TB infection should be considered during initial diagnostics. This consideration may lead to timely treatments and improved patient survival.

Management of post lobectomy subcutaneous emphysema; a case report with literature review

Introduction

Subcutaneous emphysema is an extremely rare complication after lobectomy. The current study aims to report a case of lung cancer developing extensive subcutaneous emphysema after lobectomy.

Case presentation

A 73-year-old man presented with dyspnea and cough for one month duration associated with wheeze and sputum. He was a chronic heavy smoker (100 pack/year). Work up revealed squamous cell carcinoma. Although he had poor pulmonary function tests, he underwent left upper lobectomy. On the fifth postoperative day, he was discharged from the hospital as there was no air leak and the lung remained expanded 15 hours after clamping of the thoracostomy tube. Two days later, the patient developed generalized subcutaneous emphysema. The patient was re-admitted to the hospital and a thoracostomy tube was inserted. The lung expanded upon insertion while the subcutaneous emphysema remained the same and even slightly increased over night. A 3 cm incision was made at the left infra-clavicular area and a negative pressure applied to it. The subcutaneous emphysema completely subsided a few hours after this intervention.

Discussion

Because of the benign course, the majority of cases of subcutaneous emphysema (mild to moderate) only need nonoperative management alongside treatment of the predisposing factors. These patients may need nothing other than bed rest, good analgesia, supplemental oxygen, and reassurance.

Conclusion

Subcutaneous emphysema after lobectomy prolongs hospital stay. It mainly occurs in cases with poor pulmonary function tests, steroid use, and those with extensive adhesion.

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Subcutaneous emphysema is one of the complications following thoracic surgery.

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Subcutaneous emphysema might be a benign and self-limiting condition.

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It might be a serious condition that ends with respiratory failure and death.

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In this report, a case of lung cancer developing subcutaneous emphysema after lobectomy discussed.

Non-invasive ventilation (NIV) induced bilateral subcutaneous emphysema in SARS COV-2 patient: A rare occurrence

A patient with coronavirus disease-2019 (COVID-19) developed bilateral subcutaneous emphysema involving the neck and upper chest following the institution of non-invasive ventilation (NIV) for worsening hypoxia. We discuss the various causes, differentials and successful management of this patient.

An atlas overview of characteristic features of tuberculosis that may be encountered at autopsy

Tuberculosis (TB) is a bacterial infection caused by Mycobacterium tuberculosis. Although primarily a disease of the respiratory system it may be found in any organ or tissue. Global population movements and the emergence of resistant strains are contributing to increasing numbers of cases in certain populations. Subtlety of symptoms and signs, chronicity of disease and failure to seek medical assistance may result in the diagnosis only being made at the time of autopsy. For this reason forensic pathologists need to understand the protean manifestations of the disease and the variable mechanisms by which TB may cause death. This atlas overview provides descriptions of the pathological manifestations of TB in a variety of organs with accompanying illustrations. It serves as a summary of conditions that should be checked for at autopsy in suspected or confirmed cases.

Pulmonary aspergilloma with subcutaneous fistula resulting in massive hemoptysis & subcutaneous emphysema

Aspergillomas growing in pre-existing lung cavities can lead to presentations of hemoptysis. We present a case of a 73-year-old male with non-small cell lung carcinoma (NSCLC) and known 4 cm left cavitary lesion in the left upper lobe presenting with cough and hemoptysis, leading to the diagnosis of a pulmonary aspergilloma complicated by chest wall subcutaneous emphysema due to cavitary-subcutaneous fistula in the setting of excessive cough. This case sheds light on subcutaneous emphysema as a potential rare complication of aspergillomas in patients without prior trauma.

An Interesting Case of Dysphagia in a HIV Patient

Oesophageal tuberculosis is a rare disease. Tuberculosis (TB) can cause dysphagia due to oesophageal ulcers, Tracheo-Oesophageal Fistulas (TOFs) and an extrinsic compression which is caused by the mediastinal lymph nodes. A 33-year-old gentleman was admitted to our hospital for the evaluation of fever, dysphagia and cough. His chest X-ray was suggestive of miliary tuberculosis. A CT scan of his chest revealed miliary tuberculosis, mediastinal lymphadenopathy and pneumomediastinum. His sputum AFB (acid-fast bacilli) test was positive. An upper gastrointestinal endoscopy revealed a large ulcer in the oesophagus with a fistulous opening which was suggestive of a tracheo-oesophageal fistula. A biopsy from the ulcer was positive for AFB. The test for HIV-1 was positive. A nasogastric feeding tube was placed and the Anti Tubercular Therapy ( ATT) was started. The main aim of this case report is to sensitize the clinicians about the fact that Tuberculosis can present with dysphagia, especially in HIV patients.

Broncho pleuro subcutaneous fistula with subcutaneous emphysema: A rare presentation of pulmonary tuberculosis

Subcutaneous tissue emphysema is observed in a several clinical settings but spontaneous subcutaneous emphysema in the absence of pneumothorax with broncho pleuro subcutaneous fistula is rare. We report a case of spontaneous subcutaneous emphysema secondary to cavitary pulmonary tuberculosis in the absence of pneumothorax.